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Veterans of the Vietnam War, Inc.  Phone:
805 South Township Blvd.           (570) 603 - 9740    MEMBERSHIP
Pittston, PA  18640-3327                              APPLICATION
__________________________________________________________________________________

                             MEMBERSHIP ELIGIBILITY:
ALL VETERANS AND CONCERNED CITIZENS ARE WELCOME AND ENCOURAGED TO JOIN.
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                              PERSONAL INFORMATION
_______/_______/______                  NOTE: ENTER ALL DATES AS MONTH / DAY /YEAR
SOCIAL SECURITY NUMBER
____________________________              ______________________            ______
          LAST NAME                             FIRST NAME                   M. I.
__________________________________                                     ___________
           STREET                                                      APT. NUMBER
__________________________________                _________       ________-_______
            CITY                                    STATE         9 DIGIT ZIP CODE
(_______) _____________   ____/____/____     ______________         ______________ 
  AREA CODE PHONE NUM.    DATE OF BIRTH      MARITAL STATUS           DEPENDENTS
           MILITARY INFORMATION (FROM DD-214)                ATTACH COPY OF DD-214

___________________          ______________   SERVED IN VIETNAM:      (YEARS ONLY)
BRANCH (AR NA AF MC CG RC)   SERVICE NUMBER      FIRST TOUR: FROM:______ TO:______
___________________          ____/____/_____  
TYPE OF DISCHARGE              DATE ENTERED      SECOND TOUR: FROM:______TO:______
_______________________      ____/____/_____
SERVED IN VIETNAM (Y,N)      DATE DISCHARGED     THIRD TOUR:  FROM:______TO:______
                             ______________
                               MOS NUMBER        FOURTH TOUR: FROM:______TO:______
                                                              

I hereby swear to uphold the Constitution                 DUES PAID:______________
of the United States of America and the                   AMOUNT:_____$20.00______
By-Laws of The Veterans of the Vietnam War, Inc.          RECEIVED BY:____________ 
________________________________________        ____/____/____
                SIGNATURE                            DATE

LIFE MEMBERSHIP - $200                                       ATTACH COPY OF DD-214
PAYMENTS IN 8 MONTHLY $25 INCREMENTS
                               
   FLAG OFFER              'People Who Care'
                             NON-PROFIT ORGANIZATION